Medical History Form — Stayton Veterinary Hospital

Please complete the form below.

Owner name

First Name

Last Name

Pet insurance / policy #

PET INFORMATION

Pet name

Breed

Sex

Spayed / neutered?

Color

Age

HEALTH HISTORY

Length of ownership

How did you aquire your pet?

Additional pets in home

Please list all.

Where does your pet stay?

Is your pet microchipped?

Pets typical temperament or behavior

Known allergies (environmental, flea, food, etc.)

If any, please list.

Previous surgeries, medical problems or chronic issues

Current medications

If any, please list.

Current flea / heartworm preventatives

If any, please list products.

Previous veterinarian

TRAVEL HISTORY

If your pet has travelled or lived outside of Oregon, please specify.

Does you pet get boarded or groomed?

REPRODUCTIVE HISTORY

If your pet spayed / neutered, at what age?

If your patient is intact, have they bred previously?

If so, how many litters has your pet had?

When was the last litter?

YYYY

When was their last heat cycle?

YYYY

Any history of a blood transfusion?

If yes, please list when.

YYYY

Stayton Veterinary Hospital

We are currently scheduling appointments both in the clinic as well as curbside for those who are interested. When calling to schedule, please notify a staff member which appointment option would work best for you and your pet.

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CONTACT US

1308 North First Avenue
Stayton, OR 97383
503.769.7387 (PETS)
503.769.9832 fax
Email Us

Office Hours

Monday-Friday 7:30 AM–8 PM
Saturday 9 AM–5 PM
Sunday Closed

Meet the Doctors

Michael Reynolds, DVM
J effrey Brubaker, DVM
B rittany Hale, DVM
Emma Herdener, DVM
Megan Neuhoff, DVM

Quick Links

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